In-Hospital Outcomes of Patients With Pulmonary Hypertension and Cirrhosis: A 6-Year Population Cohort Study of Over One Million Patients

Introduction: There is a paucity of data on the influence of sex, race, insurance, pulmonary hypertension-related complications, and cirrhosis-related complications on mortality, hospital length of stay (LOS), and total hospital charges. The aim of this study was to identify risk factors in a national population cohort (in the USA) admitted to hospital between 2012 and 2017.

Methods: All patients aged > 18 years with pulmonary hypertension and cirrhosis, who had been admitted to hospital between 2012 and 2017, were identified from the US Nationwide Inpatient Sample (NIS), a large publicly available all-payer inpatient care database in the USA. Multivariate regression analysis was used to estimate the odds ratios of in-hospital mortality, average length of hospital stay, and hospital charges, after adjusting for age, gender, race, primary insurance payer status, hospital type and size (number of beds), hospital region, hospital teaching status, and other demographic characteristics.

Results: Our study identified 1,111,594 patients who had been discharged from hospital from 2012 to 2017. Of these patients, 355,455 were admitted with pulmonary hypertension, with 9.8% having cirrhosis as a complication (n = 34,986). The analysis revealed that patients with both pulmonary hypertension and cirrhosis compared to patients with only pulmonary hypertension experience increased mortality, hospital LOS, total hospital charges, and pulmonary hypertension-related and cirrhosis-related complications. Independent positive predictors of mortality were Asian/Pacific Islander race and "other" insurance status (worker's compensation; other US health benefits plans [CHAMPUS/TRICARE, CHAMPVA, Title V]). Independent positive predictors of increased hospital LOS were black race and "other" patients (more than one race/mixed). Independent positive predictors of increased total hospital charges were male gender, Hispanic ethnicity, Asian/Pacific Islander race, and other insurance status. Pulmonary hypertension-related complications (cor pulmonale, pulmonary embolism, hemoptysis, cardiac arrest, atrial fibrillation, ventricular tachycardia) and cirrhosis-related complications (ascites, hepatorenal syndrome, hepatic encephalopathy, variceal bleeding, portal hypertension) were independent positive predictors of mortality, hospital LOS, and total hospital charges.

Conclusions: Patients with pulmonary hypertension and cirrhosis have increased mortality and hospital utilization compared to patients with only pulmonary hypertension. We identified key drivers for these outcomes. Targeted interventions, such as novel medications, right-to-left shunts, more evaluations for lung transplantation, and reversal of pulmonary vacular remodeling, are needed for the subgroups identified in this study in order to improve outcomes.